Catching the signs early

The revised guidelines for treating gestational diabetes mellitus (GDM) in India by the Union Ministry of Health are likely to have far-reaching implications for maternal and child health in the country. Launched in February, they make screening for GDM in pregnant women universal.

All women who visit an ante natal clinic during their term will now have to be tested.

The first test, which involves orally administering 75g of glucose solution, should be done during first contact as early as possible in the pregnancy. If negative, the second test should be done during 24-28 weeks of pregnancy.

“It is important to ensure the second test as many pregnant women develop blood sugar intolerance during this period (24-28 weeks),” the document notes. “Moreover, only one third of GDM positive women are detected during first trimester.”

The condition:

GDM is defined as Impaired Glucose Tolerance (IGT) with onset or first recognition during pregnancy. Worldwide, one in 10 pregnancies is associated with diabetes, 90% of which are GDM.

It increases the risk to pregnant women and newborns and leads to poor pregnancy outcomes.

She adds that while access to antenatal care has increased, universal screening for GDM has not yet been operationalised across the country, bringing focus and urgency to an issue that needs to be tackled ‘at the womb.

It is now accepted across the world that pregnant women need to be tested irrespective of their age, weight, number of pregnancies, or other issues.

A cycle:

Dr. V. Seshiah, founder patron, Diabetes in Pregnancy Study Group in India (DIPSI), an organisation that reports practice guidelines for GDM in India, says: “If you do not control diabetes during pregnancy, a number of things will go wrong, with both the mother and the foetus.

Also, about 10% of the people will have trans-generational diabetes.

If the baby is female, she will develop GDM later, and if the infant is male, he will go on to develop a pre-diabetic condition called IGT.

It is a vicious cycle and it will have to be broken.”

In 2010, he spearheaded what is possibly the only field study in the country, on GDM. Done in Chennai and its suburbs, it found that the prevalence of GDM was 17.8% in the urban setting, 13.8% in the semi-urban areas and 9.9% in rural areas.

We are now attempting to conduct a nation-wide study and form a GDM registry so we understand the issue better.

On treatment:

The other key aspect of the revised guidelines is treatment of GDM.

If diagnosed, a woman will be given a meal plan to follow for at least two weeks.

“If her blood sugar rests at 120 after fasting, then it has worked for her.

This is the case for about 80% of all pregnant women who have GDM. For those it does not work on, the idea is to give an inexpensive drug (metformin) to control blood sugar.

If even this does not work, then the recommendation is to start the woman on insulin. In a public health setting, this is a practical, workable alternative to immediately starting all GDM pregnant women on insulin.